Provider Demographics
NPI:1841357464
Name:NORTHSHORE MEDICAL CLINIC P C
Entity type:Organization
Organization Name:NORTHSHORE MEDICAL CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIUDARA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-627-2869
Mailing Address - Street 1:7786 MULLETT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-9056
Mailing Address - Country:US
Mailing Address - Phone:231-627-2869
Mailing Address - Fax:231-627-2869
Practice Address - Street 1:7786 MULLETT LAKE RD
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-9056
Practice Address - Country:US
Practice Address - Phone:231-627-2869
Practice Address - Fax:231-627-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005875207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI111350021Medicaid
MI1651630495OtherBS OF MI
5163049Medicare ID - Type Unspecified
E26180Medicare UPIN